Tag Archives: Weill Cornell Medical College

Products from Amazon.com

Think about this the next time you fill your plate with kale or spinach: a study published recently in JAMA Ophthalmology, found that boosting leafy green vegetable intake is associated with a reduced risk of developing glaucoma, a leading cause of blindness.

Harvard researchers analyzed the dietary information reported by more than 100,000 men and women in two long-term studies, each lasting more than 25 years. Those who ate the most leafy greens had a risk of developing glaucoma that was 20% to 30% lower than that of those who ate the least. What’s the link? Glaucoma causes damage to the optic nerve, through increased pressure from fluid in the eye or impaired blood flow to the optic nerve. Leafy greens are loaded with nitrate, which the body converts to nitric oxide. “Nitric oxide is important for maintaining optimal blood flow, and possibly for keeping eye pressure low” speculates Dr. Jae Hee Kang, the lead author of the study and a Harvard Medical School assistant professor. The study doesn’t prove that leafy greens reduce glaucoma risk; it only shows an association between the two. Eating leafy greens is also linked to lower rates of inflammation, cancer, heart disease, and even macular degeneration.

Current combination therapy can be individualized to cure chronic infections in 40 to 80 percent of cases.

The consequences of being infected with hepatitis C can take years to appear. So while new cases of the disease have fallen sharply over the past few decades, many people infected years ago are only beginning to learn they carry the virus, and to grapple with its potentially serious effects.

For many, there is good news. Half of all chronic infections can now be cured through a therapy using a combination of drugs. But hepatitis C remains a wily virus, often lying low for years and then following a course so unpredictable that doctors sometimes aren’t sure whether to recommend treatment or advise patients to watch and wait.

The biggest obstacle to effective treatment remains the fact that a majority of the estimated 3.2 million Americans who harbor chronic hepatitis C aren’t even aware they have it. In four out of five people, there are no symptoms when the infection first occurs.

“Most of the people we see discovered they have chronic hepatitis C when they went to donate blood or had a physical exam in order to get insurance,” said Dr. Bruce R. Bacon, director of the division of gastroenterology and hepatology at Saint Louis University School of Medicine.

Almost a third of those exposed to hepatitis C recover fully; their immune systems rout the virus and eliminate it. About 70 percent develop chronic infections, which carry a significant risk of cirrhosis, or scarring, of the liver and liver cancer. Paradoxically, people who become sickest soon after being infected are most likely to fight off the virus, whereas those who have few if any initial symptoms are at greatest danger of suffering persistent infection.

The treatment currently recommended for chronic hepatitis C combines ribavirin, an antiviral drug, with interferon, a substance that increases the immune system’s virus-killing power. The treatment offers a lifelong cure for more than half of patients. But because the drugs are expensive and can have serious side effects, and because the course of disease varies so much from person to person, the decision to start therapy poses tough questions.

“About one-third of people with chronic hepatitis will go on to develop cirrhosis of the liver,” said Dr. Jay H. Hoofnagle, director of the Liver Disease Research Branch at the National Institutes of Health. “Only 5 to 10 percent will develop liver cancer. In other words, many people can live perfectly well with chronic hepatitis infection and never have any problems. The trouble is we can’t tell who will do well and who will die of the disease.”

Nor can doctors predict with certainty how patients will respond to the combination therapy. In 25 to 30 percent of patients, interferon produces anxiety and depression, sometimes so extreme that sufferers have attempted suicide. It can also cause debilitating flu-like symptoms.

“I can usually get anyone through two or three months of interferon and ribavirin. Beyond that, it gets really tough,” Dr. Hoofnagle said. “At least 10 percent of patients can’t make it through the recommended course of therapy.”

Fortunately, physicians are getting better at optimizing the benefits and controlling some of the unwanted side effects, thanks in part to new insights into the virus. Researchers have discovered that hepatitis C occurs in at least six forms, called genotypes. Genotype 1 is the most common and also the hardest to treat, requiring 48 weeks of treatment. Only about 40 percent of people with this subtype get rid of the virus. Genotypes 2 and 3 can be successfully treated in just 24 weeks, eliminating the virus in about 80 percent of cases.

The more rapidly virus levels begin to fall in patients, the better the odds of a cure. By monitoring levels of the virus in blood, some doctors say, it’s now possible to individualize the course of treatment.

“I call it the accordion effect,” said Dr. Ira Jacobsen, chief of the division of gastroenterology and hepatology at Weill Cornell Medical College in New York. “If virus levels drop off very quickly, we can shorten the course of therapy. If the response is slow, we can lengthen it, sometimes to as much as 72 weeks, and improve the chances of success.”

Shortening the course of therapy remains controversial because of the risk of relapse after the treatment is stopped. Relapse occurs when lingering viruses not eradicated by the medication multiply and surge back.

Antidepressant drugs, meanwhile, are being employed to ease psychiatric side effects. And doctors are getting better at predicting who will suffer depression after starting interferon.

“Not surprisingly, people with a history of depression are at greater risk,” said Dr. Francis Lotrich, assistant professor of psychiatry at the University of Pittsburgh. He and his colleagues have also observed that people with chronic sleep problems are also more likely to have trouble with depression. The reason is not clear, but studies are under way to see if improving people’s sleep with the use of insomnia medication or other techniques can lower the risk of psychiatric side effects.

The best medicine is prevention, and it’s here that the biggest gains have been won against hepatitis C. The number of new infections per year in the United States has plummeted from 240,000 in the 1980s to about 19,000 in 2006. Experts credit a screening test that now prevents hepatitis C from spreading via blood transfusions and organ transplantation, as well as public health messages aimed at discouraging the use of shared needles, which is the leading route of transmission.

In the absence of an effective vaccine, such messages, backed up by intensified surveillance, will remain the chief defense against this virus. In 2003, chronic hepatitis B and C became notifiable diseases that must be reported to federal health officials, enabling them to track new cases nationwide. In 2004, New York State began its own enhanced viral hepatitis surveillance network.

Two years ago, the program demonstrated its usefulness when officials in the Erie County Department of Health detected a cluster of cases centered in one zip code in suburban Buffalo.

“All we had at first was a bunch of dots on a map,” said Dr. Anthony J. Billittier IV, the Erie County health commissioner. Investigators went into the community and identified about 20 young people who were injecting drugs and sometimes sharing needles. The county responded by intensifying prevention efforts, including a free needle exchange.

“We’ve made a lot of progress against hepatitis C, but there’s still a lot to do,” Dr. Billittier said. “One one thing we know about this virus is it’s not going away.”

Newer surgical techniques reduce the risk involved with having a vasectomy.Vasectomy is a simple, painless procedure that is very effective in preventing pregnancy. Men usually have no side effects from vasectomy, and no change in sexual performance or function.

They are also strikingly little-used. About 500,000 American men have the operation each year. More than twice as many women undergo tubal ligation for permanent contraception, even though that operation costs three to four times as much, requires general anesthesia and an abdominal incision, and carries a small but real risk of serious complications.

“There’s something about having a surgeon fiddling around down there with a scalpel that makes even tough guys squeamish,” said Dr. Marc Goldstein, director of the Center for Male Reproductive Medicine and Microsurgery at the Weill Medical College of Cornell University in New York.

And then there are the misconceptions that discourage many men from having vasectomies, especially the widespread and groundless worry that the procedure will lower testosterone levels and affect sexual performance.

Whatever the reasons in the United States, the situation is not the same among men everywhere. By the time they reach their 50s, roughly half of men in New Zealand have undergone vasectomies, according to Dr. Sabanegh, compared with fewer than one in six in the United States. In Canada, vasectomies outnumber tubal ligations.

Experts hope that recent advances in vasectomy techniques will ease some of the fears.

The chief advance is the no-scalpel vasectomy, a technique pioneered in China in the 1970s that has been steadily gaining popularity in the United States. In a traditional vasectomy, doctors make two half-inch incisions on either side of the scrotum to sever the vas deferens, the two narrow tubes that carry sperm from the testicles during ejaculation. The no-scalpel approach does away with the need for incisions.

In the new technique, doctors use their fingers to locate the vas deferens by feel through the thin skin of the scrotum.

“Once we’ve located the vas, we make a tiny poke-hole over it,” said Dr. Phillip Werthman, director of the Center for Male Reproductive Medicine and Vasectomy Reversal in Los Angeles. The hole can be gently expanded in a way that pushes blood vessels aside rather than cutting through them, so there is almost no bleeding. Using a hooked instrument, surgeons pull the vas through the hole, then cut it.

“A lot of men can’t even tell where the procedure was done afterwards, the hole we make is that small,” said Dr. Goldstein, who was the first Western doctor to travel to China to learn the technique. Compared with traditional techniques, no-scalpel vasectomies result in less bleeding, less postoperative pain and quicker recovery. They also require less time to perform — a little more than 10 minutes in the hands of an experienced surgeon.

Although the traditional incision method is still more widely used, that is likely to change as more and more medical schools teach the no-scalpel approach.

In another bid to win over squeamish males, some doctors have replaced the needles used to inject anesthesia into the scrotum with high-pressure jets that deliver painkillers through the skin.

“A lot of men’s biggest fear is that needle,” Dr. Werthman said, even though the actual needle used is so narrow that most men barely feel it. “Pressure injection takes the psychological edge off that,” he said, though many patients find the loud popping sound it makes unpleasant.

In the end, the success or failure of a vasectomy depends not on how surgeons reach the vas but how they block it. Many doctors use several methods to ensure that sperm don’t find another path. Along with cutting out a small section of the tube, they may burn the inner lining of the two remaining ends, clamp them and separate them.

With current techniques, the chance of an unwanted pregnancy occurring in the first year after a vasectomy is 1 in 1,000, Dr. Sabanegh said. Some of those failures are the fault of the patient, not the procedure. Because it can take several months for sperm remaining after a vasectomy to be washed out, men are counseled to use other contraception methods until tests show that their semen is free of active sperm. Many men don’t bother. In a 2006 study of 436 vasectomies, researchers at the Cleveland Clinic Foundation found that only three out of four returned for follow-up semen analysis, and only 21 percent followed the full instructions to continue to be tested until two specimens came up negative.

Growing older has its perks — heftier income, respect of one’s peers — and its drawbacks such as, for men, a steady enlargement of the prostate gland.

Soon, men with this problem may have a broader set of therapeutic options.

A 2003 study already has revolutionized the standard of care men get for this common condition. And new ideas about treating the symptoms of prostate gland enlargement now have doctors treating men with drugs better known for their effects on erectile dysfunction and wrinkled skin.

Viagra and Botox are just two of several drugs being studied for treating problems with urination and benign prostatic hyperplasia, the term for overgrown but noncancerous prostates that occur in most men as they age.

The oft-reported numbers are startling: At least 2 of 3 sixtysomething men have symptoms of an enlarged prostate gland, the organ that produces semen. Symptoms can be merely bothersome — the need to urinate often, poor urine flow and incomplete emptying of the bladder. Or they can be serious enough to require treatment: bladder and kidney dysfunction; stones or infection in the bladder; and urinary retention — inability to urinate at all.

Drug use is fairly recent

Using drugs to treat enlarged prostates is fairly new. “Twenty years ago, we never used medications,” says Dr. Steven Kaplan, a urologist at Weill Cornell Medical College in New York. Instead, when the condition became advanced, surgeons would cut away excess tissue.

Then a five-year study of 3,047 men published in the New England Journal of Medicine in 2003 caused a shift in medical practice. It found that a combination of two drugs helped relieve symptoms and halted the progression of the condition. “Now medications are the standard of care,” says Kaplan, a coauthor of that research. Surgery is now reserved for men with very large prostates or intractable symptoms.

One of the drugs tested in that study is doxazosin (Cardura), which relaxes muscle in the prostate and bladder. This helps men maintain a steady urine stream and empty their bladders more completely.

The other drug, finasteride (Proscar), blocks the synthesis of a hormone thought to spur prostate growth and can reduce prostate size.

Study coauthor Dr. Claus Roehrborn, a urologist at the University of Texas Southwestern Medical Center in Dallas, says that interim results from a second long-term study of 4,800 men have corroborated the superiority of combination therapy, although with different drugs — the alpha blocker dutasteride (Avodart), a drug in the same class as doxazosin, and tamsulosin (Flomax), which, like finasteride, is in a class of drugs called 5-alpha-reductase inhibitors.

Doctors agree that alpha blockers are primarily responsible for ameliorating symptoms. But preventing the big risks, urinary retention and surgery, requires the combination.

And new approaches are under study. “What used to be a two-horse race has just exploded,” Kaplan says.

Prostate health is by definition a man’s issue. Yet one of the most promising new treatment drugs is borrowed from women’s troubles with urinary urgency, termed “overactive bladder” by doctors. Doctors avoided the drugs in the past, fearing that supressing bladder activity would increase the risk of urinary retention in men. That fear has not been borne out in several studies, including a 2006 trial of more than 800 men published in the Journal of the American Medical Assn. In it, tolterodine (Detrol LA), used to treat urinary incontinence, decreased urinary symptoms associated with an enlarged prostate. Side effects were minimal, and rates of urinary retention were low and unaffected by drug treatment.

No study has shown that drugs for overactive bladder are better than combination therapy, but they may be helpful in men whose symptoms are due to a bladder issue rather than the effect of the prostate leaning on the bladder, researchers say.

Another new drug development comes from anecdotal reports that men taking drugs for erectile dysfunction were urinating better. In response, drug companies, including Pfizer (which markets Viagra) and GlaxoSmithKline (which markets Levitra) and Eli Lilly & Co. (which markets Cialis) are studying their erectile dysfunction drugs in men with benign prostatic hyperplasia.

One of these studies, of vardenafil (GlaxoSmithKline’s Levitra), was published earlier this year in European Urology. In it, 222 German men were given either vardenafil or a placebo for eight weeks. Those receiving the drug reported improved urination equivalent to that obtained with Flomax, as well as improved erectile function and quality of life.

And Roehrborn this month will present results from an Eli Lilly-funded clinical trial at an American Urologist Assn. meeting showing that tadalafil (Cialis) was as effective or better than the alpha blocker drugs in improving enlarged prostate symptoms.

Roehrborn says prescribing these drugs for benign prostatic hyperplasia may help remove the stigma of erectile dysfunction. “Think about the psychology. Men take it for a medical condition, a legitimate reason. But because they take it daily, their sexual function is adequate 24/7.”

Botox possibilities

Another development in the works: Botulinum toxin (Botox), which causes muscle paralysis and is used cosmetically to treat wrinkles. A small 2006 study of 41 men, published in the journal BJU International, found improvement in lower urinary tract symptoms and quality of life when Botox was injected into the prostate. Prostate size decreased by an average of 15%, but even in subjects whose prostates did not shrink, urinary function was normalized. Additional Botox studies are underway, including one sponsored by the National Institutes of Health and led by Dr. Kevin McVary, a urologist at Northwestern University Feinberg School of Medicine in Chicago.

For now, McVary says, standard treatment means that a patient with many symptoms who desires treatment should be offered an alpha blocker. If the gland is large, he should also be offered a 5-alpha-reductase inhibitor to avoid long-term consequences. Developing an enlarged prostate is the first time many men confront the likelihood of taking drugs every day for the rest of their lives. “People still have this notion that they can ‘make the disease go away,’ ” Roehrborn says. They cannot, he adds. “You stop the medication, the prostate actually physically grows back,” he says.

But future medications will be applied with more precision, Kaplan predicts. “You have to tailor the therapy to the size of the prostate, as well as the type of symptoms,” he says. “Some prostates do better by shrinking them; some prostates do better by relaxing the muscle. . . . I think the challenge is to figure out which drugs work for which patients.”

Couples With Infertility Problems Often Focus on a Woman‘s Biological Clock and Forget About the Male Contribution.
It is well known that a woman’s ability to conceive takes a dramatic dive as she approaches 40, but, what about the male biological clock?…….click & see

Men are often the forgotten piece of the infertility puzzle, but recent research suggests that infertility or early pregnancy loss isn’t always because of an aging egg.

It appears that men older than 35 are twice as likely to be infertile as men younger than 25.

As men age, both the number and quality of their sperm decline so older men become less likely to father a child and more likely to father a child with schizophrenia, Down syndrome, or other problems.

A recent study suggests that autism, an increasing problem with no known cause, may also be linked to paternal age because men 40 years or older are almost six times more likely to have a child with an autism disorder than men younger than 30.

Miscarriages also are more common as dad gets older.

It’s not unusual for a woman to get her hormones, ovulatory function and fallopian tubes tested months before her husband has even had a basic semen analysis.

Given that 20 percent of couples are infertile because of abnormal or absent sperm and that 27 percent of infertile couples have a combination of male and female factors, it makes sense to evaluate a man’s equipment, so to speak, sooner rather than later.

While it’s true that it only takes one sperm to impregnate an egg, sperm are not particularly skilled at the whole penetration thing.

While women only need to release one egg to successfully conceive, pregnancy is unlikely to occur unless there are millions of sperm swarming around it.

That’s why the first step in an evaluation of male fertility is a semen analysis, to see how many of the little guys there are.Counts greater than 20 million are considered to be normal.

Before a proud man with a count in the zillions alerts the media, he needs to keep in mind that even if the number is high, sperm quality is also a factor.

Every sample of semen has lots of sperm that are abnormal. If more than 85 percent of the sperm don’t have heads, tails, or look funny in some way, it doesn’t bode well fertility-wise.

In addition, if a sperm looks normal but is directionally challenged, the likelihood of finding its way down the fallopian-tube highway is limited.

Anything less than 25 percent to 40 percent forward motility reduces pregnancy rates. These are all factors doctors consider when running a semen analysis.

The Source of the Problem Sometimes Solvable, Sometimes Unexplained

There are four main causes of male infertility.
In roughly 10 percent to 20 percent of infertile men, an obstruction prevents sperm from traveling from the testis (where it is produced) to the urethra.

Roughly 30 percent to 40 percent of infertile men suffer low-sperm production as a result of testicular problems, resulting from infection, drugs, radiation or environmental toxins.

While hormone levels should be tested, they are rarely the problem.

Sometimes a low-sperm count is attributed to a varicocele â€” dilated veins in the scrotum. Varicocele repair was at one time a routine procedure thought to enhance male fertility, but is now highly controversial.

Studies show that the improvement in semen quality after varicocele repair doesn’t always translate to increased pregnancy rates and can use up precious time, especially when a woman’s biological clock is ticking.
The remainder of infertility is unexplained.

Men, unlike women, produce new sperm throughout their reproductive lives.
So while a 40-year-old woman is dealing with a 40-year-old egg, sperm is never older than 3 months old regardless of the age of the man.

However, that sperm becomes lower in quality as a man ages.
Aging men have declining levels of sex hormones, and it appears that these declining levels of testosterone have a significant impact on sperm production.

This well-publicized fact is certainly part of the reason that a number of men taking supplemental testosterone have increased 210 percent since 1999.

Supplemental testosterone is no magic pill, however. While higher testosterone levels potentially, but not definitively, result in improved sperm number and quality, supplemental testosterone may also be responsible for a number of health problems such as an increased risk of prostate hyperplasia, and possibly cancer.

Treatment: No Sperm Isn’t Always No Way

What is a man to do if doctors find his sperm isn’t up to donor quality?
Testosterone supplementation is rarely the cure. Urologists who specialize in male fertility can sometimes come up with specific causes and treatment recommendations for a less than terrific semen analysis after an evaluation of the man in question.

If there are quality sperm but not a lot of them assisted reproductive techniques such as in vitro fertilization and intracytoplasmic sperm Injection (in which a sperm is actually injected into the egg) can solve the problems of many infertile couples in which a male factor is the dominant problem, but the techniques are complicated and expensive.

If sperm is being produced but is not transported properly, it can be retrieved from the testis prior to ejaculation.

Certain conditions result in an inability to make sperm and are not treatable. If that is the case, pregnancy can be achieved only with donor sperm.

What a Man Can Do Now?
Men can eat right, not smoke, and exercise regularly â€” the standard and very effective health advice that applies to so many situations â€” to help keep sperm as healthy as their biology allows.

Contrary to popular opinion, it is not necessary to replace those tight jockey shorts with baggy boxers. It really doesn’t make a difference and clearly does nothing to enhance a man’s desirability.